In this prospective observational study of Emergency Department patients with possible pulmonary embolism (PE) who underwent pulmonary computed tomography angiography (CTA), the CTA findings positive for acute embolism should be viewed with caution, especially if the suspected PE is in a distal segmental or subsegmental artery in a patient with a serum D-dimer level of ≤ 1.0 μg/ml.

The changing demographic picture in California creates a complex challenge for physicians, facilities, and an organization. In response, one strategy is a service improvement program, with demonstrated successful outcomes that combines patient satisfaction "service scores"; data segmentation by ethnicity, sex and age; and data analysis, which recognizes the demographic subsets at which physicians excel and are weak. Five case examples are described, including clinicians interacting with Chinese patients, African-American patients, and young females, and two department level interventions in urology and internal medicine.

The deeply entrenched Asian cultural practice of collusion—a secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from a patient—was studied by the Palliative Care Team. Between December 2004 and June 2008, 655 patients with advanced-stage cancers were referred to the team. Beginning in February 2005, with the implementation of awareness measures, the team was able to maintain an average awareness rate of 80% of patients.

The majority of medical adverse events are secondary to errors in communication. Review of nonoperative adverse events at Cincinnati Children's Hospital Medical Center in 2007 found that 57% were related to failure to recognize abnormal vital signs and to communicate or to address parents' or nurses' concerns. The initiation of Night Talks—a late-evening review of patients' status by physicians and nurses—reduced near misses in neurosurgical patients to zero in 201 days, a 5360% change.

A comprehensive noise-reduction project was initiated in response to low patient-satisfaction scores on an inpatient neuroscience unit. Before project initiation, decibel readings (dB) were as high as 78.1 dB (standard recommended levels are 40 dB). Postproject satisfaction scores rose to the 95th percentile by July 2008.

A pediatric intensive care unit developed a family advocacy board to assist staff in providing patient- and family-centered care. Questions asked pediatric critical care staff related to patients and families as advisors showed a statistically significant improvement postimplementation. Staff perception of the level of family involvement during and after anesthesia induction increased from 42% to 78%, and during resuscitation increased from 28% to 90%.

Case Studies

Postpartum Cardiomyopathy is a dilated cardiomyopathy defined as systolic cardiac heart failure in the last month of pregnancy or within five months of delivery. The symptoms that differentiate it from those of normal pregnancy and postpartum are chest pain, dyspnea on exertion, rales, and cough. This disorder carries a high mortality rate.

Most bariatric surgery studies have shown excellent weight-loss rates for up to two years after surgery, and that most patients maintain the loss for up to ten years. This article summarizes the bariatric surgery process through a detailed case study of how Kaiser Permanente Southern California screens, prepares, and follows patients.

The majority of adverse drug reactions are nonallergic. Of 275 individuals who reported ten or more drug "allergies," 92% were women (mean age 67 years), and 60% had a diagnosis of depression or serious mental illness. The single most important thing that clinicians can do is not to use antibiotics outside the setting of bacterial infections.

Commentary

The need for good quality and safety research has never been more imperative, but even as it is encouraged it is suppressed through institutional bias and inertia. This commentary explores implications of the application of pure science standards at the sharp end of clinical practice, where the down-and-dirty street-level improvement work happens.

As competition intensifies within the health care industry, patient satisfaction and service quality are providing the evidentiary basis for patient outcomes. We propose a conceptual model of three interrelated areas--service, health outcomes, and resource stewardship--all affected by the clinician-patient relationship, and from the perspectives of the health care organization, clinician, and patient, to define a more comprehensive measure of health care delivery performance.

Patients need to communicate with a language-concordant physician, not simply an interpreter, to receive the best medical care, bond with the physician, and be satisfied with the care experience. A Spanish Language Task Force addressed the issue of Spanish-speaking patients visiting Primary Care Departments. Not all physicians who self-identify as Spanish-speaking truly speak fluently. Once an individual assessment is completed, then a plan for concordance can be made.

Narrative Medicine

This presents a simple model as a series of metaphorical images--microscope, picture frame, mirror, and two comfy chairs--that correspond to points on a continuum of levels of control exerted by interviewers, and a second continuum, from low to high empathy.